The potential supply of organ donors. An assessment of the efficacy of organ procurement efforts in the United States.

OBJECTIVES--To estimate the potential supply of organ donors and to measure the efficiency of organ procurement efforts in the United States. METHODS--A geographic database has been developed consisting of multiple cause of death and sociodemographic data compiled by the National Center for Health Statistics. All deaths are evaluated as to their potential for organ donation. Two classes of potential donors are identified: class 1 estimates are restricted to causes of death involving significant head trauma only, and class 2 estimates include class 1 estimates as well as deaths in which brain death was less probable. RESULTS--Over 23,000 people are currently awaiting a kidney, heart, liver, heart-lung, pancreas, or lung transplantation. Donor supply is inadequate, and the number of donors remained unchanged at approximately 4000 annually for 1986 through 1989, with a modest 9.1% increase in 1990. Between 6900 and 10,700 potential donors are available annually (eg, 28.5 to 43.7 per million population). Depending on the class of donor considered, organ procurement efforts are between 37% and 59% efficient. Efficiency greatly varies by state and organ procurement organization. CONCLUSIONS--Many more organ donors are available than are being accessed through existing organ procurement efforts. Realistically, it may be possible to increase by 80% the number of donors available in the United States (up to 7300 annually). It is conceivable, although unlikely, that the supply of donor organs could achieve a level to meet demand.     

公民死亡器官捐献潜在供体转运通道建立及供体重症监护室器官维护

目的 探讨适合临床的公民死亡器官捐献(DCD)潜在供体转运通道及供体重症监护室供体维护机制.方法 首都医科大学附属北京佑安医院自2012年1月开通转运通道,至2016年6月,器官获取组织(Organ Procurement Organization,OPO)共接到DCD相关信息152例,评估152例.临床判定为潜在捐献者合格84例,访谈84例,41例潜在供体家属同意捐献.建立DCD潜在供体转运通道,一般流程下直接转运潜在供体入供体重症监护室(DI-CU),并立即进行各重要器官的评估及维护.当潜在供体在转运过程中出现生命体征的恶化,紧急情况下启动应急流程.评价潜在供者进入DICU时和捐献前各项实验室检查指标的变化.结果 自2012年首都医科大学附属北京佑安医院共接收潜在供体41例,其中男29例,女12例;年龄(35.17±19.51)岁.1例(2.4％)转运过程中出现呼吸心跳停止,3例(7.3％)因家属意愿改变而中止捐献,37例(90.2％)顺利完成器官捐献.按中国心脏死亡器官捐献分类标准进行分类,此37例中国际标准化脑死亡供体28例(75.7％),国际标准化心脏死亡供体3例(8.1％),国际标准化心脑死亡供体6例(16.2％).其中31例供体捐献器官用于移植,6例供体的器官捐献后因损伤超出标准被弃用.潜在供体入DICU时和捐献前各项化验指标变化,AST、T-BIL、D-BIL、BUN的差异有统计学意义(P＜0.05).结论 建立适合临床工作的公民死亡器官捐献潜在供体转运通道及供体重症监护室以维护器官功能、提高捐献成功率非常重要,保证了供体器官的数量及质量.     

Postmortem brain donation and organ transplantation in schizophrenia: what about patient consent?

In patients with schizophrenia, consent postmortem for organ donation for transplantation and research is usually obtained from relatives. By means of a questionnaire, the authors investigate whether patients with schizophrenia would agree to family members making such decisions for them as well as compare decisions regarding postmortem organ transplantation and brain donation between patients and significant family members. Study results indicate while most patients would not agree to transplantation or brain donation for research, a proportion would agree. Among patients who declined organ donation for transplantation or brain research, almost half of family members would have agreed to brain donation for research and over 40% to organ transplantation. Male relatives are more likely to agree to organ donation from their deceased relatives for both transplantation and research. The authors argue that it is important to respect autonomy and interests of research subjects even if mentally ill and even if no longer living. Consent may be assisted by appropriate educational interventions prior to patient death.     

Death, dying and donation: organ transplantation and the diagnosis of death

Refusal of organ donation is common, and becoming more frequent. In Australia refusal by families occurred in 56% of cases in 1995 in New South Wales, and had risen to 82% in 1999, becoming the most important determinant of the country's very low organ donation rate (8.9/million in 1999). Leading causes of refusal, identified in many studies, include the lack of understanding by families of brain death and its implications, and subsequent reluctance to relegate the body to purely instrumental status. It is an interesting paradox that surveys of the public continue to show considerable support for organ donation programmes--in theory we will, in practice we won't (and don't). In this paper we propose that the Australian community may, for good reason, distrust the concept of and criteria for "whole brain death", and the equation of this new concept with death of the human being. We suggest that irreversible loss of circulation should be reinstated as the major defining characteristic of death, but that brain-dead, heart-beating entities remain suitable organ donors despite being alive by this criterion. This presents a major challenge to the "dead donor rule", and would require review of current transplantation legislation. Brain dead entities are suitable donors because of irreversible loss of personhood, accurately and robustly defined by the current brain stem criteria. Even the dead are not terminally ill any more.     

The organ procurement problem: many causes, no easy solutions

Participants at the Second International Symposium on Organ Procurement, held in 1985 in Detroit, addressed one of the principal problems of organ transplantation: the shortage of suitable donor organs. Several factors were identified as contributing to the shortage--failure to make provision before death for donation, refusal of requests for donation by families of suitable donors, failure of hospital personnel to request donation, inability to match available organs with recipients, and improper organ allocation. The participants rejected adopting a presumed consent policy and advocated laws now being enacted in several states requiring hospital personnel routinely to request donation from family members of suitable brain dead patients.     

Non-heart-beating organ donors as a source of kidneys for transplantation: a chart review

BACKGROUND: Organ transplantation is the treatment of choice for patients with end-stage organ failure, but the supply of organs has not increased to meet demand. This study was undertaken to determine the potential for kidney donation from patients with irremediable brain injuries who do not meet the criteria for brain death and who experience cardiopulmonary arrest after withdrawal of ventilatory support (controlled non-heart-beating organ donors). METHODS: The charts of 209 patients who died during 1995 in the Emergency Department and the intensive care unit at the Foothills Hospital in Calgary were reviewed. The records of patients who met the criteria for controlled non-heart-beating organ donation were studied in detail. The main outcome measure was the time from discontinuation of ventilation until cardiopulmonary arrest. RESULTS: Seventeen potential controlled non-heart-beating organ donors were identified. Their mean age was 62 (standard deviation 19) years. Twelve of the patients (71%) had had a cerebrovascular accident, and more than half (10 [59%]) did not meet the criteria for brain death because one or more brain stem reflexes were present. At the time of withdrawal of ventilatory support, the mean serum creatinine level was 71 (29) mumol/L, mean urine output was 214 (178) mL/h, and 9 (53%) patients were receiving inotropic agents. The mean time from withdrawal of ventilatory support to cardiac arrest was 2.3 (5.0) hours; 13 of the 17 patients died within 1 hour, and all but one died within 6 hours. For the year for which charts were reviewed, 33 potential conventional donors (people whose hearts were beating) were identified, of whom 21 (64%) became donors. On the assumption that 40% of the potential controlled non-heart-beating donors would not in fact have been donors (25% because of family refusal and 15% because of nonviability of the organs), there might have been 10 additional donors, which would have increased the supply of cadaveric kidneys for transplantation by 48%. INTERPRETATION: A significant number of viable kidneys could be retrieved and transplanted if eligibility for kidney donation was extended to include controlled non-heart-beating organ donors.     

Factors influencing families' consent for donation of solid organs for transplantation.

CONTEXT: Transplantation has become the therapy of choice for patients with organ failure. However, the low rate of consent by families of donor-eligible patients is a major limiting factor in the success of organ transplantation. OBJECTIVE: To explore factors associated with the decision to donate among families of potential solid organ donors. DESIGN AND SETTING: Data collection via chart reviews, telephone interviews with health care practitioners (HCPs) or organ procurement organization (OPO) staff, and face-to-face interviews with family for all donor-eligible deaths at 9 trauma hospitals in southwestern Pennsylvania and northeastern Ohio from 1994 to 1999. PARTICIPANTS: Family members, HCPs, and OPO staff involved in the donation decision for 420 donor-eligible patients. MAIN OUTCOME MEASURE: Factors associated with family decision to donate or not donate organs for transplantation. RESULTS: A total of 238 of the 420 cases led to organ donation; 182 did not. Univariate analysis revealed numerous factors associated with the donation decision. Multivariable analysis of associated variables revealed that family and patient sociodemographics (ethnicity, patient's age and cause of death) and prior knowledge of the patients' wishes were significantly associated with willingness to donate (adjusted odds ratio [OR], 7.68; 95% confidence interval [CI], 6.55-9.01). Families who discussed more topics and had more conversations about organ donation were more likely to donate (adjusted OR, 5.22; 95% CI, 4.32-6.30), as were families with more contact with OPO staff (adjusted OR, 3.08; 95% CI, 2.63-3.60) and those who experienced an optimal request pattern (adjusted OR, 2.96; 95% CI, 2.58-3.40). Socioemotional and communication variables acted as intervening variables. CONCLUSIONS: Public education is needed to modify attitudes about organ donation prior to a donation opportunity. Specific steps can be taken by HCPs and OPO staff to maximize the opportunity to persuade families to donate their relatives' organs.     

脑死亡无偿器官捐献肝脏移植2例报道

目的总结并探讨脑死亡无偿器官捐献肝脏移植在我国临床实施的可行性.方法昆明市第一人民医院于2011年12月至2012年1月期间共完成2例脑死亡无偿器官捐献工作.2例供体确诊为脑死亡,应用机械通气、血管活性药物等治疗维持供体器官灌注.受体1男性,术前诊断乙肝后性肝硬化,肝功能失代偿,child-pugh C级,MELD评分29分;受体2男性,术前诊断乙肝后性肝硬化,原发性肝癌,child-pugh C级,MELD评分26分.结果 2例脑死亡供体均顺利无偿捐献肝脏,2例受体均顺利接受肝脏移植手术并康复出院,目前随访移植肝功能良好.结论脑死亡无偿器官捐献肝脏移植的临床实施顺利,可以在我国逐渐推广实行,对缓解我国目前器官短缺状况起到相当重要的作用.     

一例心脏死亡供体无偿捐献供肝行原位肝移植的经验和体会

目的 总结心脏死亡供体器官捐献具体流程和经验.方法 对1例潜在器官捐献者经脑死亡评估和供体器官功能评估后,纳入心脏死亡器官捐献(Donation after Cardiac Death,DCD)程序,并严格按照心脏死亡器官捐献程序进行工作.结果 本例供体成功完成了肝脏捐献及获取流程,所获取供肝成功植入受体.结论 成功获取心脏死亡供体捐献的器官,为推广心脏死亡供体器官的捐献积累了经验.     

Organ donor index: a benchmark for comparing hospital organ donor rates.

OBJECTIVE: To develop organ donor indices to assess donor rates of individual hospitals. DESIGN: Data from hospital databases were retrospectively reviewed for patient separation ICD-9-CM codes (i.e., diagnostic codes from the International classification of diseases, 9th revision, clinical modification) to identify and categories actual and potential organ donors. Organ donor indices for groups of codes and for individual hospitals were determined by dividing the number of actual donors by the total number of patients who died with the same separation ICD-9-CM codes. SETTING: The three South Australian adult tertiary hospitals in 1988-1995. PATIENTS: The 154 actual organ donors, and all patients aged less than 71 years who died with the same groups of ICD-9-CM codes as the organ donors. RESULTS: Organ donors could be classified by three groups of ICD-9-CM codes specifying diseases or pathological processes that could result in brain death. These groups were head injury (44.2% of donors), cerebrovascular accident (CVA) (42.2%), and eight "other" codes (13.6%). Differences between the head injury donor indices for the three hospitals were not significant (Hospital A, 19.1%; Hospital B, 24%; Hospital C, 21%), but there were significant interhospital differences in donor indices for the CVA group (A, 11.2%; B, 5.7%; C, 5.1%; P < 0.05) and the "other" group (A, 3.6%; B, 0.7%; C, 0.3%; P < 0.001). CONCLUSIONS: ICD-9-CM codes can be used to describe organ donors and hospital populations from which potential organ donors may be found. The casemix-controlled organ donor indices can be used to compare the organ donor rates of individual hospitals and to examine reasons for low rates (other than purely casemix variation).     

潜在器官捐赠供体的转运及器官维护经验总结

目的总结潜在器官捐赠供体的转运流程和器官维护经验。方法回顾性分析2014年1月~2015年1月我院接手的52例潜在供体临床资料、当地医院病情、转运途中紧急处理、入院后接诊及如何行器官维护等资料。结果有46例供体实行成功捐献,一共实行移植115台,其中捐献肝移植34台,捐献肾移植81台。其中2例供体在ECMO下成功实行器官捐赠术。结论正确的供体评估及安全的转运是成功捐献的前提。对极危重供体,ECMO能提高器官捐献成功率。     

Ethical issues in non-heart-beating donation

A shortage of organ donors and the large number of patients desperately waiting for kidney transplant have led to the search for new sources of transplantable organs. The waiting list has grown at an alarming rate resulting in increased waiting times and deaths. The introduction of non heart beating (NHB) donation programmes generates a lot of ethical issues. How should death of a patient be defined in the case of NHB donation? Is there a strict separation of responsibilities of the medical teams in the different phases of the procedure (patient treatment and actual donation)? How should consent be obtained? Is sufficient respect and care given to the patient and his family? How is the viability of the organs assessed and how should the organs be allocated? We believe that it is very important to debate these issues and to try to outline an ethical framework for NHB donation that can enjoy the widest possible community support.     

Attitudes, knowledge, and actions with regard to organ donation among Hong Kong medical students

OBJECTIVE. To study attitudes, knowledge, and actions of local medical students with regard to organ donation and self-perceived confidence and competence in approaching potential organ donors. DESIGN. Cross-sectional questionnaire survey. SETTING. Faculty of Medicine, The University of Hong Kong, Hong Kong. PARTICIPANTS. Medical students, years 1-5. MAIN OUTCOME MEASURES. Knowledge on various aspects of organ donation was assessed, and students' self-evaluated competence and confidence about counselling for organ donation was evaluated. Factors influencing attitudes and actions were determined. RESULTS. The response rate was 94% (655/694). A majority (85%) had a 'positive' attitude, but only a small proportion (23%) had signed the organ donation card. Inconvenience and lack of knowledge about organ donor registration, and concerns about premature termination of medical treatment accounted for such discrepancies. Socio-cultural factors such as the traditional Chinese belief in preservation of an intact body after death, unease discussing death-related issues, and family objections to organ donation were significantly associated with a 'negative' attitude. Knowledge and action increased with medical education yet only a small proportion of medical students felt competent and confident in counselling patients on organ donation. CONCLUSIONS. The medical curriculum should increase medical students' awareness of the organ shortage problem. The donor registration system should be made more convenient and public education is recommended to correct misconceptions.     

Psychosocial variables associated with willingness to donate organs.

Questionnaires were administered to 108 university psychology students to investigate attitudes and behaviour related to organ donation. Three groups (committed, uncommitted and opposed) were identified. A multivariate analysis of variance showed that, compared with uncommitted donors, committed donors felt better informed about organ donation, had discussed donation more often with family members and knew more people who had signed donor cards. The subjects in the opposed group and those in the uncommitted group cited different reasons for not signing a donor card. Empathy, religious beliefs and attitudes about death did not affect willingness to donate. Analyses of the interaction between willingness to donate one's own organs and willingness to donate those of a family member revealed a monotonic increase in willingness to donate the organs of a family member as the type of recipient became more personally relevant. Our findings indicate that when health care professionals request donor organs the potential recipients must be presented to the potential donors in a personally relevant manner. Educational programs must be developed to train medical personnel in how to effectively ask for organs without coercing the potential donor or invading the privacy of the potential recipient.     

基于ROC曲线的非亲缘造血干细胞捐献志愿者筛选标准

目的：基于ROC曲线分析方法探讨非亲缘造血干细胞捐献志愿者筛选标准。方法：采用问卷调查法收集温州市2007年至2018年间共40名成功捐献造血干细胞志愿者以及166名尚未完成捐献的入库志愿者信息,构建捐献认知、捐献意愿、捐献态度及三种得分联合检验的ROC曲线。结果：综合了捐献认知、捐献意愿及捐献态度的联合筛选方法ROC曲线下面积为0.87（95%CI：0.81～0.93）,灵敏度为70.00%,特异度为90.96%,一致率为86.89%,Youden指数为0.61。结论：增强入库志愿者对非亲缘造血干细胞捐献的认知程度,提高入库志愿者的捐献意愿与态度,有利于提高志愿者的捐献可能性,降低悔捐率。     

Public attitudes and behavior regarding organ donation

Organ transplantation has been the subject of much attention; unfortunately, relatively little has been published about public attitudes toward organ donation. To better document public perceptions on organ donation, a telephone survey of a nationally representative sample of 2,056 respondents was conducted. We found that nearly 94% of the population had heard about organ transplantation, but only 19% of these people carried donor cards. The results indicated that people are somewhat more likely to donate the organs of a relative who had just died (53%) than they are to donate their own organs (50%). People were most likely to donate kidneys (50%) and least likely to donate skin (40%). Most respondents (58%) felt that next of kin should not be able to override a person's desire to donate organs as signified by an organ donor card. Few people (7%) supported the concept of presumed consent. We conclude that while the public is supportive of organ transplantation, it is not overly enthusiastic about organ donation. Awareness of this paradox on behalf of the public may actually facilitate organ donation.     

公民逝世后器官捐献肝质量研究进展

国际规范性器官移植的供体主要来源于公民逝世后器官捐献(donation after citizen's death)。近年国际国内有关公民逝世后器官捐献肝脏质量的研究取得了长足的进展,大量降低术后早期原发性无功能、肝功能延迟性恢复等相关并发症的新疗法涌现。脑死亡捐献(donation after brain death,DBD)及心死亡器官捐献(donation after cardiac death,DCD)成为公民逝世后器官捐献肝脏的基础,DBD与DCD供体肝移植并发症及其预后成为新的关注点。     

'Brain death' and organ retrieval. A cross-sectional survey of knowledge and concepts among health professionals

A sample of 195 physicians and nurses likely to be involved in organ procurement for transplantation was interviewed about knowledge, personal concepts, and attitudes concerning "brain death" and organ donation. Only 68 respondents (35%) correctly identified the legal and medical criteria for determining death. Personal concepts of death varied widely. Most respondents (58%) did not use a coherent concept of death consistently; others (19%) had a concept of death that was logically consistent with changing the whole-brain standard to classify anencephalics and patients in a persistent vegetative state as dead. The findings demonstrate confusion about correct criteria for determining death and differences in concepts of death that might prove troublesome to the transplantation enterprise. We conclude that health professionals should do more to resolve the clinical and conceptual issues in the definition and determination of death before policies concerning organ retrieval are changed.     

我国器官捐献的困境及对策

目前,我国器官捐献率低的主要原因有传统文化影响,政策法规不完善,缺乏完善的器官捐献组织机构,社会信任危机等原因.运用综摄法对器官捐献现状及其深层原因进行剖析,提出我国应完善相关医疗政策,建立系统完善的人体器官捐献渠道,加大宣传教育力度,设立专用账户,对器官捐献者应注重人文关怀以及推广脑死亡标准等对策.